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Managing Heavy Menstrual Bleeding

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Aims & Objectives

What is heavy menstrual bleeding?

Heavy menstrual bleeding (HMB) can be defined as excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life.

(NICE guidelines for Heavy Menstrual Bleeding : January 2007)

Why is it important ?

1 in 20 women aged 30-49 years consults her GP with HMB

Once referred to gynaecologist, surgical intervention is highly likely

1 in 5 women in the UK will have a hysterectomy before age 60

In at least ½ of those who undergo hysterectomy, HMB is the main presenting problem

About ½ of all women who have a hysterectomy for HMB have a normal uterus removed

Only 58% of women receive medical therapy for HMB before referral to a specialist

NICE issued new guidelines for HMB in Jan 2007

(www.doctorsnet.uk- menorrhagia module 2004/5)

Benign: Fibroids

DUB

PID

Endometriosis

Polyps

Malignant: Endometrial Ca

Cervical Ca

Ovarian Ca

Systemic: thyroid disease

coagulation disorders

Causes For HMB & Erratic Bleeding

Case 1

A 28 year old lady comes to see you as she is tired of having heavy periods.

She says she has always had heavy and painful periods for a long time but is finally at the end of her tether with them.

What do you do first?

History

Frequency of bleeding:

- Has to change tampon and pad every 2-3 hrs

- has flooded several times and is always worried about this.

- Bleeds heavily for 4 days.

Menstrual cycle: regular 28 day cycle, bleeds for 6 days.

Pelvic pain only when menstruating

No IMB

No dyspareunia, No PCB

No discharge

Married for 8 yrs, no other partners.

Smear aged 25 - normal

PMH: Nil significant, smoker

FH: Nil signiicant.

Would you examine her?

Abdominal examination – YES

Pelvic exmination +/_ swabs – NO

O/E: Abdomen soft, no tenderness or masses.

NICE guidelines Re: abdominal examination

Abdominal examination is recommended for patients with:

Abdominal pain

Bloating

Constipation

Back pain

Urinary symptoms

Nice GuidelinesRe: pelvic examination

Pelvic examination: If history suggests HMB without structural or histological abnormality, pharmaceutical therapy can be started without pelvic examination or further investigations unless choice of therapy is the IUCD.

If history suggests HMB with structural or histological abnormality eg.IMB, post-coital bleeding, pelvic pain or pressure symptoms then pelvic examination and further investigations should be carried out.

What investigations would you request?

FBC – indicated in all women with heavy menstrual bleeding

Coagulation – only indicated if heavy bleeding since menarche, other symptoms or FH.

TFT’s and Ferritin not required unless clinically indicated.

What management options would you offer?

Nice Guidelines re: pharmaceutical options

1. Levonorgestrel-releasing intrauterine system.

IUCD which slowly releases progesterone and prevents proliferation of the endometrium.

Pelvic exam needed first

Acts as contraceptive

Side effects: Irregular bleeding, hormone related problems

2. Tranexamic Acid, NSAIDs or COCPs..

Can be used while investigations are being carried out.

Stop tranexamic or NSAIDs after 3 cycles if no improvement.

NSAIDs preferred if dysmenorrhoea

Side effects- see hand out.

3. Oral progestogen (northisterone) or Injected progestogen.

Prevent proliferation of the endometrium.

15mg daily for days 5-26 of the menstrual cycle or long acting injection.

What would you do next?

You suspect she has uterine fibroids however cannot at this stage rule out anything more sinister.

Investigations

Pregnancy Test – Negative

Urine Dipstix - NAD

FBC

USS: first line investigation for detecting structural abnormalities

Hysteroscopy – only if USS inconclusive

Results..

USS confirms large uterine fibroids, the largest being 3.6cm diameter.

Do you refer?

Yes:

“Women with fibroids that are palpable abdominally or who have intracavity fibroids and/or whose uterine length as measured at ultrasound or hysteroscopy is greater than 12 cm should be offered immediate referral to a specialist.”

What management should she be offered next?

Endometrial Ablation? No,

- This can be offered to women with small fibroids <3cm diameter

Management options

Uterine Artery Embolisation

- for women who want to preserve uterus and avoid surgery. May remain fertile.

Myomectomy

- for women who want to preserve uterus.

May remain fertile.

Hysterectomy

- if other treatments fail, if the women no longer wishes to retain her uterus or fertility

- if she has been fully informed

- if she wishes to have amenorrhoea

Case 4

A 58 year old lady has been menopausal for the past 5 years.

She comes to the surgery because she has had 2 days of period like bleeding.